-
Dit proefschrift is een uitgave van het NIVEL in 2004. De
gegevens mogen met bronvermelding (J.C.M. van Weert, Multi-Sensory
Stimulation in 24-hour Dementia Care, NIVEL 2004) worden gebruikt.
Het proefschrift is te bestellen via [email protected].
Multi-Sensory Stimulation in 24-hour Dementia Care Effects of
snoezelen on residents and caregivers Julia C.M. van Weert
-
ISBN 90-6905-696-8 http://www.nivel.nl [email protected] Telephone
+31 30 2 729 700 Fax +31 30 2 729 729 ©2004 Julia C.M. van Weert
Cover design: Arnoud van den Heuvel Photography: © Hapé Smeele
Hapé Smeele kindly gave permission to use one of his photographs
from 'Met de moed van een ontdekkingsreiziger', published by
Servire 2002, Utrecht
Word processing / layout: Doortje Saya Language consultant:
Stafford Wadsworth / Mieke van Leeuwe Printing: Twin Design All
rights reserved. No part of this publication may be reproduced,
stored in a retrieval system or transmitted, in any form or by any
means, electronic, mechanical, photocopying, recording or
otherwise, without the prior written permission of Julia CM van
Weert. Exceptions are allowed in respect of any fair dealing for
the purpose of research, private study or review.
-
Multi-Sensory Stimulation in 24-hour Dementia Care Effects of
snoezelen on residents and caregivers Zintuigactivering in de
24-uurszorg aan demente ouderen Effecten van snoezelen op
verpleeghuisbewoners en zorgverleners (met een samenvatting in het
Nederlands) PROEFSCHRIFT ter verkrijging van de graad van doctor
aan de Universiteit Utrecht, op gezag van de Rector Magnificus Prof
dr. W.H. Gispen, volgens het besluit van het College voor
Promoties, in het openbaar te verdedigen op woensdag 8 december
2004 des middags te 12.45 uur door Julia Caecilia Maria van Weert
geboren op 1 november 1962, te Zundert
-
Promotores: Prof. dr. J.M. Bensing Prof. dr. M.W. Ribbe
Copromotor: Dr. A.M. van Dulmen The research described in this
thesis was carried out at NIVEL (Netherlands Institute for Health
Services Research), Utrecht, The Netherlands. NIVEL is a
participating member of the Research Institute for Psychology &
Health, officially certified by the Royal Netherlands Academy of
Science (KNAW).
The study was financed by ZonMW; Netherlands Organisation for
Health Research and Development, research program ‘Elderly Care’.
Additional funding was provided by Foundation Central Fund RVVZ and
the Province of Zeeland. Bernardus Centre of Expertise/Fontis (Mr.
Jan Peter) performed the training ‘snoezelen for caregivers’ and
supported the implementation in the experimental wards. Barry Emons
gave discount on snoezel materials. Financial support for the
publication of the thesis was kindly provided by the Netherlands
Institute for Health Services Research (NIVEL), Alzheimer
Nederland, Internationale Stichting Alzheimer Onderzoek, Arjo
Nederland, Barry Emons and my parents.
-
niet naakt maar ontbloot het ontglipt me heel verpleegsterlijk
en dan is het nu tijd voor de l- liefde, vult mama in ik wou luier
zeggen maar dit is wel zo overtuigend nog eens, crescendo klimt het
op tegen de tegelwanden en alles wat glunderen kan glundert © 2003
Verlichtingdienst | Société Lumineuse Kijk! Mama: De Tijd
Verstrijkt www.verlichtingdienst.nl/mama
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Contents 7
Contents 1 Introduction 9 2 The effects of psychosocial methods
on depressed,
aggressive and apathetic behaviours of people with dementia: a
systematic review 29
3 The implementation of snoezelen in psychogeriatric care:
an evaluation through the eyes of caregivers 59 4 Effects of
snoezelen, integrated in 24-h dementia care,
on nurse - patient communication during morning care 85 5 The
effects of the implementation of snoezelen on nurses’
behaviour during morning care, assessed on the basis of
Kitwood’s approach to dementia care 117
6 Behavioural and mood effects of snoezelen integrated
in 24-h dementia care 139 7 The effects of the implementation of
snoezelen
on the quality of working life in psychogeriatric care 165 8
Summary and discussion 189 Samenvatting 221 Literature 235 Appendix
1 Video observations 255 Appendix 2 Gedragsobservatielijst 265
Appendix 3 Vragenlijst verzorgenden 283 Dankwoord 305 Curriculum
Vitae 309
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8 Multi-Sensory Stimulation in 24-h dementia care
-
Introduction 9
1 Introduction
-
10 Multi-Sensory Stimulation in 24-h dementia care
Introduction The study described in this thesis addresses the
implementation of a new care model in the 24-h daily care of
demented nursing home residents, called snoezelen or Multi-Sensory
Stimulation (MSS). A quasi-experimental pre-test and post-test
design was carried out, in which the implementation of a new care
model, named ‘snoezelen’, was compared to care-as-usual. The study
was conducted on twelve psycho-geriatric wards of six Dutch nursing
homes between January 2001 and February 2003. This first chapter
addresses the common features of dementia and dementia care in
Dutch nursing homes. It presents the theoretical background for the
effect study. The care model investigated (‘snoezelen’) in this
study is described and the latest scientific knowledge about its
effectiveness is given; the aim of the study, the research
questions and the design of the study are described. The chapter
ends with a detailed description of the structure of this thesis.
Background Dementia: incidence, types and development Dementia is a
disease with a high prevalence. Worldwide, the number of new cases
of dementia in 2000 was estimated at 4.6 million. About 6.1% of the
population above 65 years of age suffer from dementia, which is
about 0.5% of the world population (Wimo et al., 2003). The
essential features of dementia are multiple cognitive deficits that
include memory impairment and at least one of the following:
aphasia, apraxia, agnosia, or a disturbance in executive
functioning (the ability to think abstractly and to plan, initiate,
sequence, monitor, and stop complex behaviour) (APA, 1997).
Alzheimer’s disease is the most common type of dementia, accounting
for 50-75% of the total dementia population (APA, 1997). The
incidence of Alzheimer’s disease increases with age and is
estimated at 0.5% per year from age 65-69 to 8% per year from age
85 onward (Hebert et al., 1995). Classically, Alzheimer’s disease
has an insidious onset and the progression is gradual, but steadily
downward. The average duration from onset of symptoms to death is
8-10 year. In addition, vascular (multi-infarct) dementia is
probably the next most common type of dementia, though little is
known about its prevalence (APA, 1997). Verhey (1997) estimated
that 18% of the dementia patients are diagnosed with vascular
dementia. Since both Alzheimer’s disease and vascular dementia are
common, the two frequently coexist, although only one diagnosis may
be made during a person’s life. Vascular dementia is a dementia due
to the effects of one or more strokes on cognitive function.
Typically, it is characterised by an abrupt onset and tends to
progress in a stepwise fashion. Vascular dementia may occur any
time in late life but
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Introduction 11
becomes less common after age 75, while the incidence of
Alzheimer’s disease continues to rise (APA, 1997). The relationship
between Alzheimer’s disease and vascular dementia is complex,
because recent evidence suggests that small strokes may lead to
increased clinical expression of Alzheimer’s disease (Snowdon et
al., 1997). The remaining types of dementia account for a much
smaller fraction of the total (APA, 1997). Other types of dementia
are for instance dementia due to Lewy body disease, dementia due to
Parkinson’s disease, dementia due to Pick’s disease and other
frontal lobe dementias, dementia due to Huntington’s disease or
Creutzfeldt-Jakob disease, and dementia due to medical conditions
(e.g., structural lesions, head trauma, endocrine conditions,
nutrition conditions). Dementia is often accompanied by behavioural
and psychological disturbances that can be highly problematic for
patients and caregivers. The International Psycho-geriatric
Association has defined Behavioural and Psychological Symptoms of
Dementia (BPSD) as ‘signs and symptoms of disturbed perception,
thought content, mood or behaviour that frequently occur in
patients with dementia’ (APA, 1997). BPSD, such as aggression,
agitation, depression or apathy, occur and are problematic in up to
97 percent of the cases (Buettner et al., 1996). Dementia in
nursing homes Mental and functional loss forces a large number of
elderly people with dementia to move to nursing homes. A nursing
home is defined as an institution providing nursing care 24 hours a
day, assistance with activities of daily living and mobility,
psychosocial and personal care, paramedical care, such as
physiotherapy and occupational therapy, as well as room and board.
Nursing homes usually provide care that can be characterised as the
‘highest level of care’ (Ribbe et al., 1997). In the Netherlands
there are 330 nursing homes, with a total of 57,000 beds (27 per
1000 inhabitants aged 65 and older). About 2.5% of the population
above 65 years stay in nursing homes and another 6.5% in
residential homes or homes for the aged with a lower level of care
(Ribbe et al., 1997). The Dutch nursing home is a healthcare
institution for chronically ill persons in need of permanent
complex nursing care and is comparable to skilled nursing
facilities in the United States. It differs from nursing homes in
other countries in that the staff includes nursing assistants,
specially trained nursing home physicians, psychologists, activity
therapists, speech therapists, physical therapists, nutrition
assistants, and others, all of whom are employed by the nursing
home (Hoek et al, 2000). Medical care is provided by specially
trained physicians, who are employed by the nursing home, with an
average ration of one full-time doctor per 100 beds (Ribbe et al.,
1997). Residents are admitted to nursing homes for several reasons:
50% require long-term institutional care, 40% use predominantly
rehabilitative services, 5% have a terminal illness and another
5%
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12 Multi-Sensory Stimulation in 24-h dementia care
require special services such as the care needed by comatose
people and those on respirators (Ribbe et al., 1997). Dutch nursing
homes have separate psychogeriatric wards for dementia patients
with highly care-dependent residents, in which about 27,000
dementia patients are residing (Hoek et al., 2000). Koopmans et al.
(2003) describe an observational analysis of a cohort of residents
(n=890) from a Dutch psychogeriatric nursing home with a
prospective follow-up. According to this study, the mean time
dementia patients spend in a nursing home to death is 2.4 years,
with a wide range (0-13.2). One of seven nursing home residents
(14.2%) with dementia survive to late dementia, mostly women (90%)
with Alzheimer’s disease (60%) (Koopmans et al., 2003). The results
show that Dutch nursing home patients with Alzheimer’s disease have
a mean disease duration of 7.2 years (range 1.3-23.5), whereas
patients with vascular dementia have a mean disease duration of 5.3
years (range 0.8-15.1) (Koopmans et al., 1992; 2003). Quality of
care for demented elderly: theoretical background Once he is
institutionalized, the individual’s quality of life is often
affected by behaviour problems, such as aggression, agitation,
depression or apathy (Buettner et al., 1996). The quality of life
of demented nursing home residents depends for a major part on the
extent to which the nursing care meets the residents’ needs. Hall
and Buckwalter (1987) have developed a conceptual model, the
Progressively Lowered Stress Threshold (PSLT), which posits that
patients who have progressive dementia become less and less able to
interpret, process, and adapt to environmental stimuli. Once the
environmental demands exceed the patient’s accommodation abilities,
levels of stress increase and are manifested in, for instance,
anxiety, agitated behaviours or aggression. On the other hand,
Edelson (1984) and Norberg et al. (1986) describe psychosocial
withdrawal as a result of a lack of (adequate) stimulation whereby
individuals become apathetic or engage in self-stimulating
behaviours. Hall et al. (1987) suggest that if environmental
stimuli are manipulated by caregivers to create a supportive and
less challenging milieu for the cognitively impaired patient, then
quieter, more adaptive behaviour will replace catastrophic
reactions caused by anxiety. Kitwood developed a framework for
psychogeriatric nursing care: the Dialectical Framework (Kitwood,
1996). The central thesis in this framework is that the dementing
process arises from an interaction between neurological impairment
and social psychological processes (e.g., the interaction between
caregivers and demented elderly people). Social psychology enhances
or diminishes an individual’s sense of safety, value and personal
well-being (Kitwood, 1993a;1993b). Kitwood distinguishes
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Introduction 13
certain kinds of interaction that are harmful to those who have
dementia, and interactions that make for well-being (Kitwood,
1996). The interactions that contribute to the undermining of
personhood are called ‘malignant social psychology’. Examples of
malignant social psychology are ‘infantilization’ (treating a
person very patronizingly in the same way as a parent might treat a
very young child) or ‘disempowerment’ (not allowing a person to use
the abilities that they have; failing to help them to complete
actions that they have initiated). The interactions that are
clearly conductive to the maintenance of personhood and well-being
are named ‘positive person work’ (Kitwood, 1998). Examples of
positive person work are ‘recognition’ (acknowledging a demented
resident as a person and affirm him or her in his or her
uniqueness), ‘negotiation’ (consult the demented resident about
preferences, desires, and needs, rather then being conformed to
others' assumptions) or ‘timalation’ (the direct and pleasurable
stimulation of the senses, in a way that accords with the values
and scruples of the person with dementia) (Kitwood, 1996).
Caregivers, and especially Certified Nursing Assistants (CNAs), are
an important factor in the environment of demented nursing home
residents. According to the Dialectical Framework, there is much
that can be done by caregivers in psycho-geriatric care that
positively influences the mood and behaviour of nursing home
residents. To be able to deliver resident-oriented or
person-centred care, ‘staff-centred work environments’ or ‘type B
settings’, as described by Kitwood, are needed (1997). In type B
settings the manager’s role is more one of enabling and
facilitating than of controlling, and this involves giving a great
deal of feedback to staff. The whole staff group (manager, senior
care team and care assistants) thrives on cooperation and sharing.
There is a strong commitment to minimize the differential of power.
The organisation is highly skilled in interpersonal matters and has
well-developed communication pathways. Type B settings are sensible
to what staff members are experiencing and feeling. Each staff
member can bring matters into the open, knowing that he will not be
criticized, but given the support that he needs. Each resident is
recognised in his or her uniqueness, through a skilled combination
of empathy and personal knowledge (Kitwood, 1997). The creation of
type B settings is supposed to lead to increased quality of care,
which in turn will lead to increased quality of life for the
residents. The affective state or well-being of demented elderly
people has long received little attention, with even less concerns
to events that promote or threaten well-being. From the end of the
20th century, many caregivers prefer a person-centred approach to
care provision (Innes and Surr, 2001). Once person-centred care has
been realised, the quality of care provided for persons with
dementia improves, which will result in increased quality of life
of residents. However, a change to person-centred care is not
always easy to achieve. Kitwood argues that the belief that nurses
have in
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14 Multi-Sensory Stimulation in 24-h dementia care
the biomedical nature of dementia as the standard paradigm might
have positive advantages for them as it allows them to retreat into
emotional non-involvement when they do not have the personal
resources available to deal appropriately with people with dementia
(Adams, 1996). Meeting the psychosocial needs of demented residents
remains a challenge. How to assess the extent to which these needs
are met is another one (Innes and Surr, 2001). Quality of working
life of caregivers: theoretical background Working in health care
is characterised as emotionally demanding (Arts et al., 2001). In
dementia care, caregivers often have to deal with behavioural
problems of residents, which make their work even more demanding.
Besides, many Dutch nursing homes have a high workload, partly
caused by difficulties with the recruitment of sufficient staff
(Hoek et al., 2000). Workload originates not only from the amount
of work, but also from aspects as skill variety, autonomy and
learning opportunities or tempo and role ambiguity. High workload
may influence the level of stress reactions, job satisfaction and
burnout negatively and, consequently, the quality of care. Aspects
such as workload, job stress, job satisfaction and burnout are
associated with the concept ‘quality of working life’, which has
been given increased attention in health services research
(Beukema, 1987; Jansen et al., 1996; Bourbonnais, 1998; Kruijver et
al., 2001; Arts et al., 1999; 2001). Beukema (1987) defines quality
of working life as ‘the degree to which employees are able to shape
their jobs actively, in accordance with their options, interest and
needs’. Arts et al. (2001) integrate three models of quality of
working life into a new model containing three components: 1.
workload (organizational characteristics, job characteristics,
working conditions); 2. psychological and physical outcomes (job
satisfaction, stress reactions, burnout,
health); 3. capacity of coping (social support, personal
characteristics). In this model, a relationship between workload
and the psychological and physical outcomes of work is assumed,
having a buffer in the capacity for coping (Arts et al., 2001). In
the current study, attention is paid to the relation between the
intervention (snoezelen), workload and psychological outcomes of
work. Snoezelen Snoezelen as a care model During the last decades,
several psychosocial treatments have been developed in dementia
care (APA, 1997). One of the approaches that is becoming more and
more popular as a potential intervention on psycho-geriatric wards
is snoezelen, also referred to as Multi-Sensory Stimulation (MSS).
Snoezelen seems to fit the premises of the PSLT and the Dialectical
Framework. It was developed in the Netherlands,
-
Introduction 15
but spread rather rapidly across Europe, in particular the
United Kingdom, in the 1980s and 1990s. It is just beginning to
appear in the United States (Chitsey et al., 2002). Snoezelen can
be defined as an approach which actively stimulates the senses of
hearing, touch, vision and smell in a resident-oriented,
non-threatening environment (Kok et al., 2000). It is intended to
provide individualized, gentle sensory stimulation without the need
for higher cognitive processes, such as memory or learning, in
order to achieve or maintain a state of well-being. Traditionally,
snoezelen was applied in a special room with an array of equipment,
offering multiple stimulation, covering all the sensory channels
(i.e., a vibrating bed, soft comfortable furnishings, aroma
steamers, spotlights, mirrors and music), both to stimulate and to
relax (Noorden, 1999; Lancioni et al., 2002). In the present study,
snoezelen is extended to the 24-h daily care. Caregivers learn to
incorporate personal circumstances of the residents such as
lifestyle, preferences, desires and cultural diversity into 24-h
daily care (Noorden, 1999). By interviewing family members
(‘history taking’) and systematic observations (‘stimulus
preference screening’), the caregivers find out what stimuli the
resident enjoy most (Lancioni et al., 2002). Then, the information
is integrated in the residents’ care plan (‘snoezel care plan’).
Caregivers also learn to adapt their attitude and practical skills
to integrate multi-sensory stimuli in the care. The ultimate goal
of integrated snoezelen is, consistent with the concept of
patient-centeredness, the caregivers’ understanding of the
residents’ real needs, preferences and wishes (Bensing, 2000).
Snoezelen aims to reduce residents’ maladaptive behaviours, to
increase positive behaviours and to improve their mood. Researchers
describe the therapeutic benefits of snoezelen in terms of
relaxation, behaviour modification or improved quality of life
(Chitsey et al., 2002; Lancioni et al., 2002). Additionally,
snoezelen is used in dementia care to promote a caregiving
relationship and to reduce caregiving stress, assuming a positive
effect of the caregivers’ quality of working life (McKenzie, 1995;
Savage, 1996; Chung, 2002). Effectiveness of snoezelen Until now,
there has been limited evidence for the effectiveness of snoezelen.
In the last decade, a number of studies have been carried out that
evaluate the impact of snoezelen sessions in a special room on the
resident’s behaviour as well as on adaptive and performance skills
within and after the snoezelen sessions. Although the majority of
these studies did report within-session positive effects, most of
the studies were not methodologically sound, e.g., contained no
comparisons between treatment and control groups which are
essential to demonstrate that snoezelen prevents deterioration
(Lancioni, 2002). Chung et al. (2002) conducted a Cochrane review
and found two randomised clinical trials (RCTs) of sufficient
scientific quality, evaluating the effects of snoezelen in a
snoezel room (Baker et al., 1997; 2001;
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16 Multi-Sensory Stimulation in 24-h dementia care
Holtkamp et al., 1997; Kragt et al., 1997). In the RCTs,
positive immediate outcomes in reducing maladaptive behaviours and
promoting positive behaviours are found. Kragt’s subjects presented
significantly fewer behavioural problems (e.g., apathy,
restlessness) during the snoezelen sessions than the control
sessions (Kragt et al, 1997; Holtkamp et al., 1997). Baker’s
subjects were more responsive to their surrounding environments
immediately after the sessions (Baker et al., 1997; Chung et al.,
2002). Yet, the variation in outcome measurements is too high to
account for solid scientific evidence of snoezelen on other
outcomes. Moreover, carryover and long-term effects of snoezelen
are not evident. Non-controlled trials also report rather limited
and inconsistent longer-term effects of snoezelen (Lancioni et al.,
2002). So far, there is hardly any evidence of expected benefits of
snoezelen for staff. Most of the available studies only
investigated the effects of snoezelen on the mood and behaviour of
dementia patients. There are no RCTs available in which the
effectiveness of snoezelen on the quality of working life is
studied. Hence, Lancioni et al. (2002) recommend to determine the
influence of multisensory (snoezelen) programmes on the quality of
working life of staff involved in such an approach. Objectives and
research questions Review of the literature First, a literature
study was conducted to investigate the effects of existing
psychosocial methods, including snoezelen, on the behaviour of
demented persons. Earlier research has shown that aggression,
depression and apathy are the behavioural disturbances accompanying
dementia that nurses experience as the most problematic. However,
there is limited insight into which psychosocial treatments are
effective in reducing these behaviours. The aim of the systematic
review was to establish the extent of scientific evidence for the
effectiveness of psychosocial methods on reducing depressed,
aggressive or apathetic behaviours in people with dementia.
Therefore, 13 psychosocial treatments were selected, i.e., 10
psychosocial methods, distinguished by the American Psychiatric
Association (1997), supplemented with three treatments (i.e.,
gentle care, passivities of daily living, psychomotor therapy) that
are often used in the Netherlands. Intervention study Although the
review concludes that there is scientific evidence that snoezelen
in a snoezel room reduces apathy in people in the latter phases of
dementia, no generalizing effects of snoezelen on behaviour and
mood of demented elderly could be established. The limited
carryover and long-term effects suggest that a continuous and
ongoing programme should be implemented (Chung, 2002). Moreover,
the care
-
Introduction 17
for demented nursing home residents demands interventions that
are easily implemented by less skilled caregivers in daily contact
with those with dementia (Sambandham, 1995). Therefore, an
intervention study was conducted that focus on the implementation
of an integrated snoezelen approach in the 24-h daily care, carried
out by Certified Nursing Assistants (CNAs). In the Netherlands,
snoezelen usually gets no or little attention during the basic
vocational education of nursing assistants. Bernardus
Experisecentre/Fontis, a nursing home with training center
specialised in snoezelen, has developed a four-day course
‘snoezelen for caregivers’, which can be attended by staff members
in addition to their basic education level. A resident-oriented
attitude, comparable with ‘positive person work’ as described by
Kitwood (see “Theoretical background”), is an important condition
to integrate snoezelen care successfully in psychogeriatric care.
Therefore, the training ‘snoezelen for caregivers’ pays attention
to person-centred care as well as to the application of
multi-sensory stimulation. To implement the snoezelen care model
successfully, psycho-geriatric units need to make organizational
adaptations towards a ‘type B setting’ (see “Theoretical
background”). These organizational adaptations are necessary to
become a stimulating and safe environment for caregivers, providing
the conditions to apply the new care model. The final aim of the
intervention is to increase mood and behaviour of demented
residents and, therefore, the residents’ quality of life. The
switch in caregiver behaviour from task-oriented care to
resident-oriented or person-centred care is considered as a
prerequisite to reach this final aim, as is visualised in figure
1.1.
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18 Multi-Sensory Stimulation in 24-h dementia care
Figure 1.1 Research model ‘residents’ quality of life’
Intervention Implementation of snoezelen in 24-h daily care
Caregivers’ behaviour Nonverbal and verbal communication �
Quality of caregivers’ behaviour � Positive behaviour � Negative
behaviour �
Residents’ behaviour Nonverbal communication� Mood and behaviour
of residents � Well-being � BPSD �
The intervention is supposed to increase not only the residents’
quality of life, but also the caregivers’ quality of working life,
as is visualized in figure 1.2. The figure is based on Arts’ model
‘Quality of working life’ (Arts, 2001). Figure 1.2 Research model
'caregivers’ quality of working life'
Intervention Implementation of snoezelen in 24-h daily care
Workload Job characteristics - skill variety - learning
opportunities - autonomy - having a voice Working conditions - time
pressure - role conflict
Psychological outcomes Perceived problems - with general
dementia care - with specific
behaviours of demented elderly
Stress reactions Job satisfaction Burnout
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Introduction 19
Research questions of the intervention study The effectiveness
of snoezelen as a care model, integrated in 24-h dementia care, has
never been studied before. This paragraph describes the study’s
research questions and objectives. Research question 1 1. 'How is
the implementation of snoezelen evaluated by caregivers in
psycho-
geriatric care?' 1a. 'What factors facilitate or hinder the
implementation of snoezelen in the
experimental wards in the eyes of the caregivers?' 1b. 'Do
caregivers experience positive changes at the level of caregivers,
residents
and the organisation, as a result of the implementation of
snoezelen in 24-h care?'
Many intervention studies lack an investigation of the extent to
which the intervention was implemented as intended, which makes
outcome measures difficult to interpret. Therefore, the first
objective of our intervention study was to evaluate the
implementation process of snoezelen on the experimental wards and
to identify facilitating and hindering factors. Other health care
institutions might take advantage of these findings when they
intend to implement the snoezelen care model. Research question 2
2a. ‘What are the effects of the integration of snoezelen in 24-h
care on the
actual verbal and non-verbal communication of CNAs during
morning care?’
2b. ‘What are the effects of the integration of snoezelen in
24-h care on the actual verbal and non-verbal communication of
demented nursing home residents during morning care?’
The second aim of the intervention study was to examine the
effects of the implementation of snoezelen on the non-verbal and
verbal communication of CNAs and residents during morning care. In
particular, it was hypothesized that the intervention would lead to
the following measurable changes: �� an increase of
rapport-building non-verbal communication of both CNAs and
residents (e.g., gazing, affective touch, smiling); �� an
increase of the affective or socio-emotional verbal communication
of CNAs
that is needed to establish a trusting relationship (e.g.,
showing empathy, social talk, validation);
�� a decrease of negative affective verbal communication of both
CNAs and residents (e.g., showing disapproval or anger);
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20 Multi-Sensory Stimulation in 24-h dementia care
�� a decrease of negative instrumental communication, initiated
by CNAs (e.g., questions about facts, cognitive knowledge).
Research question 3 3. ‘What are the effects of the
implementation of snoezelen on the quality of
CNAs’ behaviour during morning care?’ The third objective of the
intervention study was to gain insight into the extent to which
CNAs succeeded to improve the quality of their behaviour during
morning care, by performing a more person-centred approach. In
particular, it was hypothesized that the intervention would lead to
the following measurable changes: �� an increase of positive
behaviours of CNAs; �� a decrease of negative behaviours of CNAs;
�� an increase of sensory stimulation by CNAs. Research question 4
4. 'What are the effects of snoezelen on the behaviour and mood of
demented
nursing home residents?' The fourth aim of the intervention
study was to investigate whether snoezelen, applied by CNAs and
integrated in 24-h daily care, leads to a positive change in mood
and behaviour of demented nursing home residents as compared to
residents receiving usual care, i.e., without snoezelen. In
particular, it was hypothesized that the intervention would lead to
measurable, positive changes in �� well-being: more
happiness/contentment, more enjoyment, better mood; �� adaptive
behaviour: more attentive and responding to environment, more
own
initiatives, better relationship to caregiver; �� maladaptive
behaviour: less non-social behaviour, apathetic behaviour, loss
of
decorum, loss of consciousness, rebellious behaviour, restless
behaviour, disoriented behaviour, anxiety, aggression, agitation
and depression.
Research question 5 5. 'What are the effects of the
implementation of snoezelen on the quality of
working life of caregivers in psycho-geriatric care?'
-
Introduction 21
The fifth objective was to find out whether the implementation
of snoezelen had a positive effect on the quality of working life
of CNAs who apply snoezel care, compared to CNAs who apply usual
care. In particular, it was hypothesized that the intervention
would lead to measurable, positive changes in �� Workload: the
activities that someone has to carry out in a particular
environment, classified in job characteristics (skill variety,
learning opportunities, autonomy, having a say) and working
conditions (time pressure, role ambiguity). Positive effects of the
implementation of
snoezelen were especially assumed on working conditions. ��
Psychological outcomes of CNAs : the subjective experience of the
actual
workload, operationalised in perceived problems, stress
reactions, job satisfaction and burnout.
Design of the study A quasi-experimental pre-test and post-test
design was carried out. The study was performed in twelve
psycho-geriatric wards of six Dutch nursing homes. The six
experimental wards received a training ‘snoezelen for caregivers’
to implement snoezelen in 24-h care. In the six control wards,
usual care was continued. Randomisation took place at ward level by
way of an independent person drawing lots drawn from a sealed
container. Nursing units were randomised within each nursing home
(every nursing home delivered an experimental and a control ward)
instead of randomising entire nursing homes. Therefore, the
experimental and the control group were considered to be comparable
in terms of admission policy, capacity for psychogeriatric
residents, population of psychogeriatric residents on the ward,
composition of nursing staff, staff-client ratio, used care model
at baseline, system of resident-allocation, service types and
degree of care innovation. By interviews with staff members, these
aspects were verified. In case of allocation to the control group,
the ward had to refrain from snoezelen training or implementation
of elements from the snoezel care model during the study period.
Commitment to this and other inclusion criteria (see chapter 6)
were laid down in a co-operative agreement. Control for
contamination on the control wards was done by interviewing the
head nurses. Control on the intervention in the experimental wards
was done by participating observations in five of the six
experimental wards (Janssen, 2001; Vruggink, 2004). Measurements
were performed at baseline and after 18 months in the period
between January 2001 and February 2003. The nursing homes were
consecutively included between January (home 1) and August 2001
(home 6), in order to spread the activities with regard to the
pre-test and post-test and the intervention. The
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22 Multi-Sensory Stimulation in 24-h dementia care
measurements on the experimental and control ward of the same
nursing home were carried out at the same time. To establish the
effectiveness of snoezelen on mood and behaviour of demented
nursing home residents and work-related outcomes of caregivers, a
sample size of 120 residents and 120 CNAs was required, i.e. 10
residents and 10 CNAs per ward (power=.80, � �=.05, d=.50).
Assuming one-third non-response (no proxy informed consent of
residents’ legal guardians), fifteen moderately to severely
demented residents that fulfilled the inclusion criteria for
residents (see chapter 6) had to be residing per ward at baseline.
The selection of residents that fulfilled the inclusion criteria
was done in cooperation with the head nurse. A larger sample could
not be recruited at the beginning, as no more eligible residents
were expected per ward. Therefore, loss to follow-up (e.g., due to
death) had to be handled. To accommodate the dropouts occurring
during the study period, a second cohort of subjects was recruited
by replacing the dropouts from the first cohort of residents. The
experimental wards were instructed to apply snoezelen care to as
many (new) residents as fulfilled the inclusion criteria.
Consequently, the dropouts could be replaced during the study
period, so that at least 60 residents could be included at
post-test. Loss to follow-up among residents was expected to be
around 50%. Three months before the post-test, a new informed
consent procedure was followed to obtain proxy consent from legal
guardians of new, eligible residents. Loss to follow up among CNAs
(e.g., by changing jobs) was also handled by the replacement by new
CNAs. Loss to follow-up among caregivers was expected to be around
35%. The new CNAs received ‘training on the job’ from the head
nurse or the ‘coordinator sensory stimulation’ and attended the
follow-up meetings in order to be able to apply the snoezelen
method. They were also coached on how to bring the care into
conformity with the snoezel (care) plans of the residents. As
dropouts were substituted by new residents or CNAs, multilevel
analysis, carried out with MLwiN-software, was used for analyzing
the data. By using multilevel analysis, the statistical analyses
were carried out following the ‘intention-to-treat’ principle: all
data available could be included in the analysis, which implies
more power for the analysis than the ‘complete cases only’ approach
employed by other techniques. A mixed model of multilevel analysis
for repeated measurements was chosen, which takes into account all
available data in an adequate way: the paired samples of completers
(included in pre-test and post-test) as well as the unpaired
pre-measurement or post-measurement data of non-completers
(included in pre-test or post-test). The correlated measurements of
completers are controlled for by modelling the covariance between
the pre-measurement and post-measurement at the resident or CNA
level. To compare the rate of change across the two groups, the
-
Introduction 23
mean pre-test post-test differences in the experimental group
were tested against the mean pre-test post-test differences in the
control group. Relevant covariates were selected for adjusted
analysis to correct for differences in the residents’ conditions
and background characteristics of residents or CNAs. Figure 1.3
shows the most important elements of the intervention and the
measurements. The post-test was planned 18 months after the
pre-test, because 15 months was considered to be the minimum time
needed for successful implementation of the new care model
(Finnema, 2000). This time was required to effect a change from
task-oriented care to resident-oriented care and to effect changes
at organizational level. At the caregivers’ level, the
implementation of snoezelen in 24-h care required several
interventions to improve knowledge, skills and habits.
Interventions at the organisational level were needed to guarantee
persistent care changes. These concerned, for instance, adaptations
of procedures and activities (e.g., breakfast project with
nice-smelling food), investments in snoezel materials or
adaptations in the daily schedule (e.g., no longer waking up of
residents who prefer to sleep late, no force to be ready with the
morning care before the coffee break). The data collection to
evaluate the implementation process of snoezelen on the
experimental wards was carried out using a questionnaire about the
training, interviews about the implementation and attendance to the
follow-up meetings, also regarding implementation.
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24 Multi-Sensory Stimulation in 24-h dementia care
Figure 1.3 Design of the study
Month 1 2 3-20 3 from 4 from 4 from 4 from 6 7,14,18 12,16 18
21
Experimental Group 6 psycho-geriatric wards Informed consent
procedure Pre-test Measurements: - observations on the ward by CNAs
- video-recordings during morning care - medical background data by
physician From pre- to post-test Implementation of snoezelen in
24-h daily care: - in-house training ‘snoezelen for caregivers’ -
start implementation in daily care - study group - stimulus
preference screening of residents - writing of snoezel care plans -
supervision meetings: follow-up meetings (3x per ward) general
meetings (2x) Informed consent procedure to include new residents
Post-test Measurements: - observations on the ward by CNAs -
video-recordings during morning care - medical background data by
physician
Control Group 6 psycho-geriatric wards Informed consent
procedure Pre-test Measurements: - observations on the ward by CNAs
- video-recordings during morning care - medical background data by
physician From pre- to post-test Care-as-usual: - continuation of
the usual care at baseline Control for contamination: - interview
with head nurse (15 month after
pre-test) Informed consent procedure to include new residents
Post-test Measurements: - observations on the ward by CNAs -
video-recordings during morning care - medical background data by
physician
The effectiveness of snoezelen on nurse-patient communication
and the quality of nurses’ behaviour was studied by analysing
video-recordings of the morning care. To analyse the non-verbal and
verbal nurse-patient communication during morning care in detail,
the video-recordings were observed directly on the computer by
independent assessors, using the computerized observation system
‘Observer’ and an adaptation of the Roter Interaction Analysis
System (RIAS) (Caris-Verhallen, 1999; Kerkstra et al., 1999; Roter,
1989). To assess the quality of nurses’ behaviour, a 4-point
observation scale was developed, based on the Dialectical Framework
of Kitwood (1996, 1997, 1998). The effectiveness of snoezelen on
the behaviour and mood of nursing home residents was studied in two
ways. First, by conducting ward observations, using existing,
valid
-
Introduction 25
and reliable observation scales and investigating several
behaviour patterns of demented elderly, such as agitation,
aggression, depression, apathy and anxiety. Second, by analysing
video-recordings, using observation scales on behaviour and mood of
demented residents. The effectiveness of snoezelen on the quality
of CNAs’ working life was investigated by an extensive
questionnaire, existing of valid and reliable scales measuring
workload, perceived problems, stress reactions, job satisfaction
and burnout. Structure of the thesis Chapter 2 gives a systematic
literature review of the effectiveness of psychosocial methods on
depressed, aggressive and apathetic behaviours of people with
dementia. In Chapter 3, the implementation process on the
experimental wards is evaluated. The quantitative results of the
evaluation of the training ‘snoezelen for caregivers’ are
presented, as well as the qualitative results representing the
opinion of caregivers. The chapter describes what actually has been
done during the implementation period. Facilitating interventions
and barriers are identified and an overview is given of the changes
that have been realised, in the eyes of caregivers, on the level of
residents, caregivers and organisation. Chapter 4, 5, 6 and 7
present the quantitative results of the trial. Chapter 4 reports
the effectiveness of snoezelen on nurse-patient communication
during morning care. The non-verbal and verbal communication of
both nurses and residents during morning care is described, based
on a detailed analysis of the video-recordings by independent
observers. In Chapter 5, the effectiveness of the implementation of
snoezelen on the quality of nurses’ behaviour during morning care
is presented. The chapter describes whether a change in nurses’
behaviour towards a more person-centred attitude has been achieved
on the experimental wards, using an observation scale that was
developed for this study. Chapter 6 addresses the effects of
snoezelen on the behaviour and mood of demented nursing home
residents. The results of observations, carried out by CNAs on the
ward, and video-observations of the morning care, assessed by blind
observers, are provided. In Chapter 7 the results of the study into
the effects of snoezelen on the quality of working life of CNAs are
presented, in terms of perceived problems, job satisfaction and
other work-related outcomes. Finally, in Chapter 8, the results of
our study are discussed. The main findings are summarized and
methodological reflections are made. The relationship between the
findings is discussed as well as the relevance of the study.
Recommendations for practice and future research are made.
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26 Multi-Sensory Stimulation in 24-h dementia care
Chapter 2 to 7 are submitted for publication in scientific
journals. As a consequence, there is some overlap between the
chapters, in particular with regard to the description of the
‘methods’ and the ‘intervention’. Chapter 3 was published by the
International Journal of Nursing Studies (Van Weert et al., 2004).
Chapter 4, 6 and 7 are in press.
-
Introduction 27
-
Literature review 29
2 The effects of psychosocial methods on depressed, aggressive
and apathetic behaviours of people with dementia
A systematic review This chapter has been submitted for
publication as: Verkaik R, Weert JCM van, Francke AL. The effects
of psychosocial methods on depressed, aggressive and apathetic
behaviours of people with dementia: a systematic review
(submitted).
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30 Multi-Sensory Stimulation in 24-h dementia care
Abstract This systematic review seeks to establish the extent of
scientific evidence for the effectiveness of 13 psychosocial
methods for reducing depressed, aggressive or apathetic behaviours
in people with dementia. The guidelines of the Cochrane
Collaboration were followed. Using a predefined protocol, ten
electronic databases were searched, studies selected, relevant data
extracted and the methodological quality of the studies assessed.
With a Best Evidence Synthesis the results of the included studies
are synthesized and conclusions about the level of evidence for the
effectiveness of each psychosocial method are drawn. The review
concludes that there is some evidence that Multi-Sensory
Stimulation / snoezelen in a Multi-Sensory Room reduces apathy in
people in the latter phases of dementia. Furthermore there is
scientific evidence, although limited, that Behaviour
Therapy-Pleasant Events and Behaviour Therapy-Problem Solving
reduce depression in people with probable Alzheimer's disease who
are living at home with their primary caregiver. There is also
limited scientific evidence that Psychomotor Therapy Groups reduce
aggression in a specific group of nursing home residents diagnosed
with probable Alzheimer's disease. For the other 10 psychosocial
methods there are no or insufficient indications that they reduce
depressive, aggressive or apathetic behaviours in people with
dementia. Although the evidence for the effectiveness of some
psychosocial methods is better than for others, overall the
evidence remains quite modest and further research needs to be
done. Introduction Dementia is often accompanied by behavioural and
psychological disturbances that can be highly problematic to
patients, their informal and formal caregivers. The
-
Literature review 31
International Psychogeriatric Association has assigned the term
Behavioural and Psychological Symptoms of Dementia (BPSD) to these
disturbances. They define BPSD as ‘signs and symptoms of disturbed
perception, thought content, mood or behaviour that frequently
occur in patients with dementia’. BPSD can be clustered into one of
five syndromes: psychosis, aggression, psychomotor agitation,
depression and apathy (Finkel and Costa e Silva, 1996). Various
studies have been conducted into the prevalence of BPSD and
describe figures between 58% and 100% of patients with at least one
of the five syndromes (Zuidema and Koopmans, 2002). Earlier
research shows that most serious problems experienced by nurses
caring for patients with dementia concern depression, aggression
and apathy (Ekman et al., 1991; Halberg and Norberg, 1993; Kerkstra
et al., 1999). One way to support nurses who are often confronted
with these problems is through the development of guidelines. The
guidelines should be based on psychosocial methods that are
scientifically proven to reduce the BPSD. A systematic review of
the existing research literature can help to determine the
effectiveness of psychosocial methods in reducing BPSD. In recent
years some systematic literature reviews have already been
conducted. Following the review method of the Cochrane
Collaboration these literature reviews explored the effects of
Validation, Reminiscence, Reality Orientation, Snoezelen (Neal and
Briggs, 2002; Spector et al., 2002; Spector et al., 2002; Chung et
al., 2002). These reviews did not result in solid conclusions,
because of, among others, the limited number of studies that could
be included. For this reason and because of the lack of systematic
reviews of some other psychosocial methods (e.g. psychomotor
therapy, behaviour therapy, gentle care) a new, large-scale
systematic review has been conducted as a first phase in a research
project aimed at the development of evidence based guidelines for
nurses (including nursing assistants) working with clients
suffering from dementia. In this review the amount of evidence for
the effectiveness of thirteen psychosocial methods to reduce
depression, aggression and apathy in people with dementia is
established. Not only methods employed by nurses were studied but
also methods utilized by other disciplines, such as by activity
therapists, psychologists and psychotherapists. If these methods
should prove to be effective they could be adapted to nursing
practice. Previous reviews included only Randomized Controlled
Trials (RCTs). In order to increase the chances that solid
conclusions could be drawn, non-randomized controlled trials (CCTs)
were also included in the review. The possible selection biases
produced by the inclusion of CCTs are controlled for in the data
synthesis of the review. In this article the methods, results and
conclusions of the review are presented and discussed. Methods
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32 Multi-Sensory Stimulation in 24-h dementia care
The review has been conducted following the guidelines of the
Cochrane Collaboration. This entails that (1) most steps in the
review are performed by two researchers independently, (2) the
researchers work in accordance with a predefined protocol and (3)
the methodological quality of the studies is taken into account
during the data synthesis. The method is described in detail in the
Cochrane Reviewers’ Handbook (Clarke et al., 2002). Inclusion
criteria Types of studies. Randomized controlled trials (RCTs) and
controlled clinical trials (CCTs), also including cross-over trials
with a sufficient wash-out period (depending on the specific
psychosocial method), were included in the review when there was a
full article or description of the study obtainable. Types of
participants. People were included who have been diagnosed as
having a type of dementia according to DSM-III-R, DSM-IV, ICD-10 or
other comparable instruments. Both inpatients and outpatients and
all severities of dementia were included. Types of psychosocial
methods. The 10 psychosocial methods distinguished by the American
Psychiatric Association were included, their names sometimes
adjusted to current practice (APA, 1997), supplemented with three
methods (in table 2.1 with an asterisk) that are well known to be
used in the Netherlands.
-
Literature review 33
Table 2.1 Included methods
Behaviour oriented
Emotion oriented Cognition oriented Stimulation oriented
- Behaviour therapy
- Supportive psychotherapy - Validation / Integrated
emotion-oriented care - Multi-Sensory Stimulation/Snoezelen -
Simulated presence therapy - Reminiscence - Gentle care* -
Passivities of Daily Living (PDL)*
- Reality orientation - Skills training
- Activity/recreational therapy - Art therapy - Psychomotor
therapy*
Types of outcome measures. Only studies using depression,
aggression or apathy as an outcome measure were included. Search
method From September 2002 to February 2003 we searched in various
international and national bibliographical databases for
intervention studies that fulfilled all four inclusion criteria.
Ten databases were searched (see table 2.4). The databases were
searched using the following strategy that was formulated in PubMed
and adapted to the other databases:
dementia [MESH] AND (psychotherapy OR complementary therapies OR
psychosocial treatments OR psychosocial* OR emotion-oriented care
OR emotion-oriented* OR validation therapy OR validation-therapy OR
Multi-Sensory Stimulation OR sensory stimulation OR sensory
integration OR snoezelen OR simulated presence therapy OR simulated
presence* OR reminiscence therapy OR reminiscence* OR warm care OR
gentle care OR passivities of daily living OR PDL OR behavioural
therapy OR behaviour* therapy OR cognitive therapy OR reality
orientation OR ROT OR skills training OR recreational therapy OR
psychomotor therapy OR psychomotor* OR psychomotor-therapy) Limits:
Clinical Trial
The complete Specified Trials Register of the Cochrane Dementia
and Cognitive Disorders Group (CDCIG) was searched. Identified
systematic reviews were screened for additional references.
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34 Multi-Sensory Stimulation in 24-h dementia care
Selection method A first selection for inclusion was performed
by the first author (RV). On the basis of titles and abstracts all
studies that clearly did not meet one of the four inclusion
criteria were excluded from the review. If there was any doubt
about meeting the inclusion criteria, the full article was ordered.
A second selection was made by two reviewers independently (RV,
JvW). On the basis of the full articles the two reviewers checked
if the studies satisfied all four criteria. Disagreements regarding
inclusion status were resolved by discussion. If no consensus could
be met, a third reviewer (AF) was consulted. Assessment of
methodological quality The methodological quality of the selected
RCTs and CCTs was rated by a list developed by Van Tulder (1997).
This list, containing specified criteria proposed by Jadad (1996)
and Verhagen et al. (1998) consists of 11 criteria for internal
validity, 6 descriptive criteria and 2 statistical criteria (table
2.2). The list was developed in close contact with the Dutch
Cochrane Centre. The criteria mentioned in table 2.2 were
operationalised to the specific area of psychogeriatrics by the
first author. After discussion with the second and third author,
agreement about the operationalization was reached. An example is
the operationalization of criterion e 'was the care provider
blinded for the intervention?' to 'did the care provider know which
was the experimental condition and which the control?'. More
information about the operationalization of the criteria is
available from the first author. All criteria were scored as yes,
no, or unclear. Equal weight was applied to all items. Studies were
considered to be of ‘high quality’ if at least 6 criteria for
internal validity, 3 descriptive criteria and 2 statistical
criteria were scored positively. Otherwise, studies were considered
of ‘low quality’. The methodological quality of the included trials
was independently assessed by two reviewers (RV, JvW). The
assessments were compared and disagreements were resolved by
discussion.
-
Literature review 35
Table 2.2 Criteria List for the Methodological Quality
Assessment Patient selection: a) Were the eligibility criteria
specified? Yes/No/Don’t know b) Treatment allocation: 1) was a
method for randomization performed? Yes/No/Don’t know 2) was the
treatment allocation
concealed? Yes/No/Don’t know c) Were the groups similar at
baseline regarding the most important diagnostic indicators?
Yes/No/Don’t know Interventions: d) Were the index and control
interventions explicitly described? Yes/No/Don’t know e) Was the
care provider blinded for the intervention? Yes/No/Don’t know f)
Were co-interventions avoided or comparable? Yes/No/Don’t know g)
Was the compliance acceptable in all groups? Yes/No/Don’t know h)
Was the patient blinded to the intervention? Yes/No/Don’t know
Outcome measurement: i) Was the outcome assessor blinded to the
interventions? Yes/No/Don’t know j) Were the outcome measures
relevant? Yes/No/Don’t know k) Were adverse effects described?
Yes/No/Don’t know l) Was the withdrawal/drop out rate described and
acceptable? Yes/No/Don’t know m) Timing follow-up measurements: 1)
was a short-term follow-up measurement performed? Yes/No/Don’t know
2) was a long-term follow-up measurement performed? Yes/No/Don’t
know n) Was the timing of the outcome assessment in both groups
comparable? Yes/No/Don’t know Statistics: o) Was the sample size
for each group described? Yes/No/Don’t know p) Did the analysis
include an intention-to-treat analysis? Yes/No/Don’t know q) Were
point estimates and measures or variability presented for
Yes/No/Don’t know the primary outcome measures? Internal validity
criteria: b.1, b.2, e, f, g, h, I, j, l, n, p. Descriptive
criteria: a, c, d, k, m.1, m.2. Statistical criteria: o, q.
Data extraction Two reviewers (RV, JvW) independently documented
the following characteristics of each included study: 1. Study
design. 2. Participants: inclusion and exclusion criteria; number
of patients; sex; age; type
of dementia and diagnostic instruments used; severity of the
dementia and diagnostic instruments used; duration of the dementia;
inpatients/outpatients; duration of institutionalization.
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36 Multi-Sensory Stimulation in 24-h dementia care
3. Psychosocial method: type of psychosocial support method in
the experimental condition(s); type of psychosocial support in the
control condition(s), features of methods (duration, frequency,
setting).
4. Outcome measures/instruments (aggression, depression or
apathy): instrument(s) used; timing of measurements; number of
participants who completed the study in the experimental and
control conditions; mean scores for experimental and control
conditions; standard deviations in experimental and control
conditions.
5. A short description of the results. The documentations of the
two researchers were compared and disagreements were resolved by
discussion. Data synthesis Owing to diversity in the features of
the psychosocial methods and in outcome measures, it was not
possible to pool the data for each type of method. Therefore a
‘Best Evidence Synthesis’ was conducted (see table 2.3) based upon
those developed by Van Tulder et al. (2002) and adapted by
Steultjens et al. (2002). Table 2.3 Principles of Best Evidence
Synthesis Evidence: Provided by consistent, statistically
significant findings in outcome measures in at least two high
quality RCTs. Moderate evidence: Provided by consistent,
statistically significant findings in outcome measures in at least
one high quality RCT and at least one low quality RCT or high
quality CCT. Limited evidence: Provided by statistically
significant findings in outcome measures in at least one high
quality RCT Or Provided by consistent, statistically significant
findings in outcome measures in at least two high quality CCTs (in
the absence of high quality RCTs). Indicative findings: Provided by
statistically significant findings in outcome measures in at least
one high quality CCT or low quality RCT (in the absence of high
quality RCTs) No/Insufficient evidence: If the number of studies
that have significant findings is less than 50% of the total number
of studies found within the same category of methodological quality
and study design Or In case the results of eligible studies do not
meet the criteria for one of the above stated levels of evidence Or
In case of conflicting (statistically significantly positive and
statistically significantly negative) results among RCTs and CCTs
Or In case of no eligible studies
-
Literature review 37
The Best Evidence Synthesis is conducted by attributing various
levels of evidence to the effectiveness of the psychosocial
methods. The synthesis takes into account the design, the
methodological quality and the outcomes of the studies. Sensitivity
analysis A sensitivity analysis was performed in order to identify
how sensitive the results of the Best Evidence Synthesis are to
changes in the way it was conducted. The Best Evidence Synthesis
was repeated in two different ways, using the following principles:
– Low quality studies were excluded. – Studies were rated
‘high-quality’ if they at least met 4 criteria of internal
validity
(instead of 6). – The results of the altered syntheses were then
compared with those of the Best
Evidence Synthesis and the sensitivity of the method was
described. Results Selection of studies Application of the search
strategy to the specified databases resulted in 3.977 hits. Based
on titles and abstracts, the first author selected 189 studies
which possibly met the four inclusion criteria. Table 2.4 shows the
number of studies that each database contributed. A total of 177
studies were tracked down by library services, contacting authors
of studies, contacting authors of other reviews and by contacting
the Cochrane Dementia and Cognitive Improvement Group. Despite
these activities, 12 studies could not be retrieved. Four of these
studies investigated the effects of validation (Buxton, 1996;
Esperanza, 1987; Pretczynski et al, 2002; Snow, 1990), two studied
the effects of psychotherapy (Burns, 2000; Marino-Francis, 2001),
two the effects of Multi-Sensory Stimulation (Creany, 2000; Sansom,
2002), one the effects of reminiscence (McKiernan et al, 1990) and
one the effects of behaviour therapy (Howard, 1999). Of the
interventions in the other two studies (North of England Evidence
Based Guideline Development Project, 1998; Sharp, 1993) it was not
clear which psychosocial method they concerned.
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38 Multi-Sensory Stimulation in 24-h dementia care
Table 2.4 Results of database searches Source Hits Number of
new
possibly relevant studies
PubMed (1966 to 6 December 2002) 535 51
Cochrane (CENTRAL/CCTR, Cochrane 2002, issue 3 ) 101 32
Cochrane Database of Systematic Reviews (Cochrane 2002, issue 3
) Hand search 4 reviews and 3 protocols
29
PsychInfo (1872 to 2002 September week 1) 130 34
EMBASE (1990 to 2002 week 40) 418 6
CINAHL (1982 to 2002 August week 5) 152 6
INVERT (1993 to Autumn 2002) 16 2
NIVEL full catalogue 37 4
Cochrane Specialized Register CDCIG (CENTRAL/CCTR, Cochrane
2002, issue 4)
2580 8
SIGLE (1980-2002/6) 8 -
Other 12
Cochrane Database of Abstracts of Reviews of Effectiveness
(Cochrane 2002, issue 4) Hand search 5 reviews Hand search 17
reviews found in search PubMed, PyscInfo, EMBASE, CINAHL and other
sources
5
Total 3977 189
The 177 studies were independently assessed on the four
inclusion criteria by the first two authors. The evaluations of the
two authors were compared for all four inclusion criteria which
showed a consensus on 79% of the evaluations. After discussion all
disagreements were resolved. Twenty-three of the 177 articles
fulfilled all four inclusion criteria. Of these articles eight
described the same four studies; these were combined. This left us
with a total of 19 studies to be included in the review. Of the 154
excluded studies, 89 were excluded because they did not meet one of
the four selection criteria: 33 did not use a control group or a
cross-over design, 21 studies did not use the formulated outcome
measures, 17 did also include subjects that were not demented and
18 studies evaluated other methods than the 13 that were selected.
Of the other 65 excluded studies, two were excluded because the
articles did not contain a complete description (Brack, 1998;
Ermini-Fünfschilling et al, 1995). Sixty-three studies did not meet
more than two of the selection criteria. Data-extraction and
quality assessment
-
Literature review 39
This section describes the features of each study and the rating
of their methodological quality. The description includes the items
mentioned in the Methods section about data-extraction as far as
they were described in the articles. Table 2.5 contains an overview
of the main characteristics of the included studies. The text
following table 2.5 describes the more precise content of the
psychosocial methods, the control groups(s) that were used and the
results of each study. Validation integrated emotion-oriented care
Four studies into the effects of validation were included in the
review. Validation aims to restore self-worth and reduce stress by
validating emotional ties to the past (APA, 1997). The first
included study, reported by Finnema et al. (1998, 2000) and Dröes
et al. (1999), investigated the effects of Integrated
Emotion-Oriented Care on depression, aggression and apathy on
nursing home residents in the Netherlands. Integrated
emotion-oriented care is a combination of methods and techniques
from emotion-oriented approaches, based on the needs of the
resident in question. The method mainly consists of validation,
supplemented by other emotion-oriented methods (see table 2.1).
Participants in the experimental group received 24-h
Emotion-Oriented Care for 7 months by trained nursing assistants.
Participants in the control group received usual nursing home care.
Finnema et al. and Dröes et al. did not find significant changes in
the depression, aggression or apathy scores of the participants who
received Emotion-Oriented Care or in participants that received
usual care. The second study that measured the effects of
validation was conducted by Toseland et al. (1997) and investigated
the effects of structured Validation Therapy group sessions on
depression, aggression and apathy of nursing home residents in the
United States. Participants in the experimental group received
structured Validation Therapy group sessions of 30 minutes, four
times a week, during a period of one year. There were two types of
control groups. The first control group received Social Contact
group sessions with the same intensity as the experimental group
received Validation Therapy group sessions.
-
Table 2.5 Characteristics of included studies (E=Experimental
group, C=Control group) Treatment type and first author
Quality Design Participants (N; sex; age)
Participants (Type and severity dementia)
Outcome measures Results 1)
Validation, Finnema et al., 1998; 2000, Dröes, 1999
High RCT N completers=146 (67 exp; 79 contr.) Female n=118 Male
n=28 Age exp M=83,8 SD 5.3 Age contr. M=83,6 SD 5.8
107 Alzheimer’s Disease 29 Dementia Syndrome 8 Alzheimer’s and
Vascular 2 Amnestic Syndrome Severity dementia (GDS-score) Mild n=7
Moderate-Severe n=69 Severe-Very severe n=70
Apathy: -Behavioural Assessment Scale for
Intramural Psychogeriatrics (BIP)_Subscale apathy
-Dutch Assessment Scale for Elderly Patients (ASEP)_Subscale
inactivity
Depression: -Cornell Scale for Depression in dementia
Aggression: -Cohen-Mansfield Agitation
Inventory (CMAI)_Subscales verbally and physically aggressive
behaviours
-Dutch Assessment Scale for Elderly Patients (ASEP)_Subscale
aggression
Apathy: No significant changes Depression: No significant
changes Aggression: No significant changes
-table 2.5 continued I-
-
Treatment type and first author
Quality Design Participants (N; sex; age)
Participants (Type and severity dementia)
Outcome measures Results 1)
Validation, Toseland et al., 1997
High RCT N (baseline)=88 Female n=66 Male n=22 Age exp M=87.8 SD
6.0 Age contr.1 M=87.3 SD 6.12 Age contr.2 M=87.8 SD 7.6
At least moderate level of dementia (MDS) Cognitive functioning
(errors SPMSQ): Errors exp. M=7.4 SD=2.1 Errors contr.1 M=7.5
SD=2.8 Errors contr.2 M=7.2 SD=3.0
Apathy: -Multidimensional Observation
Scale for Elderly Subjects (MOSES)_Subscale withdrawn
behaviour
Depression: -Multidimensional Observation Scale for Elderly
Subjects (MOSES)_Subscale depression Aggression: -Cohen-Mansfield
Agitation Inventory (CMAI)_Subscales verbally aggressive behaviour
(VAB) and physically aggressive behaviour (PAB)
Depression: Sign. difference after 1 year between validation
therapy group (VT) and social contact group (SC), caused by
increased depression scores of SC. No sign. differences between VT
and usual care group (UC) Aggression According to nursing staff
assessment: Sign. changes in PAB after 3 months and 1 year. Sign.
lower VAB-scores after 1 year for both VT and SC. According to
nonparticipant observers: No sign. changes in PAB. Sign. lower VAB
scores for SC
-
-table 2.5 continued II- Treatment type and first author
Quality Design Participants (N; sex; age)
Participants (Type and severity dementia)
Outcome measures Results 1)
Validation, Schrijnemaekers, 2002
Low CCT N (baseline)=151 Female=136 Male=15 Age exp. M=84.3
SD=5.5 Age contr. M=85.9 SD=5.6
Moderate to severe cognitive impairment (MMSE score) score exp.
M=10.8 SD=5.1 score contr. M=11.3 SD=5.1
Apathy: -Dutch Behaviour Observation Scale for Psychogeriatric
Inpatients (GIP)_Subscale apathetic behaviour Aggression:
-Cohen-Mansfield Agitation Inventory (CMAI)_Subscales verbally and
physically aggressive behaviours
Apathy: No significant changes Aggression: No significant
changes
Validation/ Reality Orientation, Scanland et al., 1993
Low CCT N (completers)=34 Age M=76.8 (�60)
Presence of confusion (MMSE�24)
Depression: Modified Beck Depression Inventory
Depression: No significant changes
Reality Orientation, Spector et al., 2001
Low RCT N (baseline)=35 Age M=85.7 SD=6.7
Dementia according to DSM-IV criteria Ability to communicate and
understand communication (CAPE score 1 or 0 on questions 12 and
13)
Depression: Cornell Scale for Depression in Dementia (CSDD)
Depression : Significant differences in pre-/post change
scores
-table 2.5 continued III-
Treatment type Quality Design Participants Participants (Type
and Outcome measures Results 1)
-
and first author (N; sex; age) severity dementia)
Reality Orientation, Hanley et al., 1981
Low RCT N (completers)=57 Hospital residents of long-stay
psychogeriatric unit (n=41) Residents old peoples home (n=16)
Female n=53 Male n=4
Senile dementia n=39 Arteriosclerotic dementia or Cerebral
arteriosclerosis n=9 Alcohol related dementia n=2 Korsakoff n=1 No
diagnosis n=6 Severity of dementia (Koskela test) Hospital
residents psychogeriatric unit Mild=7% Moderate=27% Grave=25%
Nursing home residents Mild=20% Moderate= 55% Grave=25%
Apathy: Geriatric Rating Scale (GRS)_Subscale
withdrawn/apathy
Apathy: No significant changes
Reality Orientation, Baldelli et al., 1993
Low CCT N (baseline)=23 Female n=23 Male n=0 Age M=84.5
SD=6.4
Senile Alzheimer’s Disease n=23 MMSE �10 and �24
Depression: Geriatric Depression Scale (GDS)
Depression: No significant changes
-table 2.5 continued IV-
Treatment type and first author
Quality Design Participants (N; sex; age)
Participants (Type and severity dementia)
Outcome measures Results 1)
-
Reality Orientation, Ferrario et al., 1991
Low CCT N (completers)=19 Female n=11 Male n=8
MMSE >18 and
-
-table 2.5 continued V-
Treatment type and first author
Quality Design Participants (N; sex; age)
Participants (Type and severity dementia)
Outcome measures Results 1)
Multi-Sensory Stimulation/ Snoezelen, Kragt et al., 1997,
Holtkamp et al., 1997
High Rcross-Over
N (baseline)=16 Female n=15 Male n=1 Age M=86
Diagnosis dementia (MMSE)
Apathy: -Dutch Behaviour Observation Scale for Psychogeriatric
Inpatients (GIP)_Subscale apathetic behaviour
Apathy: Significant effect on apathy
Multi-Sensory Stimulation/ Snoezelen, Robichaud et al., 1993
High RCT N (completers)=40 Age M=78.4
Dementia according to DSM-III-R Modified MMSE score �75
Physically able to attend the sessions
Depression: -Revised Memory and Behaviour Problems Checklist
(RMBPC)_Subscale depression
Depression: No significant effect
Reminiscence, Goldwasser et al., 1987
Low RCT N (completers)=27 Female n=20 Male n=7 Age M=82.3
Clinical diagnosis of dementia: Alzheimer’s Disease n=6
Multi-infarct n=11 Dementia secondary to a medical disorder n=10
MMSE score M=10.4
Depression: Beck depression Inventory
Depression: Significant lower self-reported depression score at
posttest. Note: Reminiscence group participants had higher
depression scores at baseline than the 2 control groups
-table 2.5 continued VI-
Treatment type and first author
Quality Design Participants (N; sex; age)
Participants (Type and severity dementia)
Outcome measures Results 1)
-
Reminiscence, Namazi et al., 1994
Low CCT N (completers)=15 Female n=15 Male n=0 Age M=81.5 SD
3.6
Alzheimer’s disease n=15 MMSE Score exp. M=13.4 SD=4.9 Score
contr.1 M=12.6 SD=3.9
Apathy: Verbal responses during session_‘Related responses 5
words’ and ‘Unrelated responses 5 words’
Apathy: No significant changes
Psychomotor Therapy, Hopman-Rock et al., 1999
High RCT N (baseline)=92 Female n=87 Male n=5 Age exp. M=83.8
SD=5.8 Age contr. M=84.2 SD=5.6
Cognitive impairment (CST-14 maximum score=14) Score exp. M=11.5
SD=3.3 Score contr. M=11.5 SD=5.7
Apathy: -Dutch Behavioural Observation Scale for Intramural
Psychogeriatry (BIP)_Subscale apathetic behaviour
Depression: -Dutch Behavioural Observation
Scale for Intramural Psychogeriatry (BIP)_Subscale
depression
Apathy: No significant changes Depression: No significant
changes
-table 2.5 continued VII-
-
Treatment type and first author
Quality Design Participants (N; sex; age)
Participants (Type and severity dementia)
Outcome measures Results 1)
Psychomotor Therapy, Dröes, 1991
High RCT N (baseline)=43 Female n=36 Male n=7 Age M=84.2
SD=5.39
Diagnosis probable dementia of Alzheimer type (DSM-III-R) MMSE
score M=12.7 SD=4.16
Apathy: -Dutch Behaviour Observation Scale
for psychogeriatric Inpatients GIP_Subscale apathetic
behaviour
Depression: -Dutch Depression list
Aggression: -Dutch Beoordelingsschaal voor
Oudere Patiënten [Assessment Scale for Elderly Patients]
(BOP)_Subscale aggression
Apathy: No significant changes. Depression: No significant
changes. Aggression: Significantly lower aggression scores in
subgroup of patients with more functional disorders than in this
type of patients in the control group
Skills Training, Meier et al.,1996
Low CCT N (completers)=53 Female=34 Male=19 Age exp. M=74.7
SD=8.7 Age contr. M=75.6 SD=7.2
Alzheimer's Disease (NINCDS-ADRDA) n=28 Vascular Dementia
(NINDS-AIREN) n=25 MMSE score Score exp. M=24.7 SD=2.9 Score contr.
M=24.6 SD=3.2
Depression: -Geriatric Depression Scale
Depression: No significant changes
-table 2.5 continued VIII
-
Treatment type and first author
Quality Design Participants (N; sex; age)
Participants (Type and severity dementia)
Outcome measures Results 1)
Behaviour Therapy, Teri et al., 1997
High RCT N (completers)=72 Female n=34 Male n=38 Age M=76.4
SD=8.2
Probable Alzheimer’s Disease (NINCDS-ADRDA criteria) MMSE score
M=16.5 SD=7.4
Depression: -Hamilton depression Scale -Cornell Scale for
Depression in Dementia
-Beck Depression Inventory
Depression: Significantly lower depression scores in both
experimental groups after 9 weeks intervention period and after 6
months follow-up
Art Therapy, Wilkinson et al., 1998
Low CCT N (completers)=15 Female n=10 Male n=5 Age exp. M=79.6
Age contr. M=80
Consultant diagnosis of dementia (DSM-IV)
Depression: -Cornell Scale for Depression in
Dementia
Depression: No significant changes
Gentle Care, Bråne et al., 1989
Low
CCT
N (baseline)=26 Age exp. M=83.5 SD=5.3 Age contr. M=81.5
SD=5.3
Patients in the experimental group were demented according to
their MMSE-score (Folstein et al., 1975).
Apathy: Depression in Dementia Scale_Subscale withdrawal
Depression: Depression in Dementia Scale_Subscale depressed
mood
Apathy: Significant changes in withdrawal change scores
Depression: No significant changes
1) Significant results are in favour of the experimental group,
unless otherwise stated. Only results concerning apathetic,
depressive or aggressive behaviour are mentioned
-
Literature review 49
The second control group continued to participate in regular
social and recreational programs. The Validation Therapy group
sessions and Social Contact group sessions were facilitated by
trained group leaders who had bachelor's degrees and previous
experience with nursing home residents. Toseland et al. found that
the first control group (Social Contact group) had higher
depression scores at post-test than at baseline, while the scores
of the Validation Therapy and the Usual Care groups had not
changed. According to blinded nursing staff assessment after three
months and one year, the Validation Therapy group participants were
physically less aggressive than the two control groups. After one
year, verbally aggressive behaviour was reduced significantly in
both the Validation Therapy group and the Social Contact group.
However, the reduced physically and verbally aggressive behaviours
were only reported by the nursing staff and were not confirmed by
the blinded nonparticipant observers. The third validation study
included, reported by Schrijnemaekers (2002), investigated the
effects of integrated emotion-oriented care on aggression and
apathy of residents in homes for the aged in the Netherlands. The
experimental group received 24-h Integrated Emotion-Oriented Care
during a period of 8 months by professional caregivers of the
nursing homes, while the control group received regular nursing
care. Schrijnemaekers found no significant differences in the
pre-/post change scores of the experimental and control groups.
Validation/Reality orientation The fourth study on validation is
also the first included study on the effects of reality
orientation, and was performed by Scanland et al. (1993) among
nursing home residents in the United States. The aim of reality
orientation is to redress cognitive deficits (APA, 1997). In
classroom reality orientation, a prepared instructor reviews facets
of reality with a small group of confused people. The first
experimental group received Validation Therapy group sessions for
30 minutes, 5 times a week, for 4 months. The second experimental
group received Reality Orientation group sessions with the same
intensity as the Validation Therapy. A third group formed the
control group and received no formal therapy. Both the Reality
Orientation group sessions and the Validation Therapy group
sessions were conducted by the same registered nurse, who had a
background in group psychotherapy. Scanland et al. measured the
effects on depression but found no significant pre-/ post change
scores in the experimental groups or the control group. Reality
orientation The second included reality orientation study, reported
by Spector et al. (2001), investigated the effects of reality
orientation on depression among nursing home
-
50 Multi-Sensory Stimulation in 24-h dementia care
residents in the United Kingdom. The experimental group received
15 sessions of Structured Reality Orientation Group Therapy, each
session lasted 45 minutes. The groups were facilitated by a member
of the research team with a staff member from the home/center as
co-facilitator. The control group received usual care. Spector et
al. found significant differences in the pre-/post change scores of
the experimental and the control group, in favor of the
experimental group. The third study on the effects of reality
orientation was performed by Hanley et al. (1981) to establish the
effects on apathy among residents of a long-stay psychogeriatric
unit of a hospital, and residents of an old peoples home in the
United Kingdom. The experimental groups received half an hour
Classroom Reality Orientation, four times a week for 12 weeks by a
therapist. The control groups received usual care. Hanley et al.
found no significant differences in the apathy change scores of the
experimental and the control group. The fourth study on the effects
of reality orientation was conducted by Baldelli et al. (1993)
among institutionalized people with Alzheimer's Disease in Italy.
The experimental group received formal Classroom Reality
Orientation Therapy for 1 hour, 3 times a week, during a period of
3 months. The control group received usual care. Baldelli et al.
measured the effects on depression but found no significant changes
in the scores of the experimental and control group. The fifth
included study on the effects of reality orientation, reported by
Ferrario et al. (1991), investigated the effects on depression and
apathy among institutionalized psychogeriatric patients in Italy.
The experimental group received formal Classroom Reality
Orientation Therapy for 1 hour, 5 times a week, for 24 weeks by a
therapist. The control group received usual care. The apathy scores
in the experimental group were significantly lower than at pretest,
while the scores in the control group had not changed. There were
no significant changes in the depression scores. Multi-Sensory
Stimulation/Snoezelen The aim of Multi-Sensory Stimulation/
snoezelen is to maintain or improve contact with demented people
and to improve their well-being by positive stimulation of their
senses (visual, auditory, tactile, olfactory and gustatory
stimulation). The first included study on the effects of
Multi-Sensory Stimulation was conducted by Baker et al. (2001)
among people living at home with their primary caregiver and
attending a hospital day center in the United Kingdom. People in
the experimental group received 1:1 Multi-Sensory Stimulation
sessions in a Multi-Sensory Stimulation room for 30 minutes, twice
weekly, for 4 weeks. The control group attended 1:1 Activity
Therapy sessions for 30 minutes, twice weekly, for 4 weeks. The
sessions were conducted by two teams of 'keyworkers', which
consisted of a member of staff from
-
Literature review 51
the day hospital, an occupational therapist or a psychology
assistant. Baker et al. found that the experimental group had a
significantly greater increase in attentiveness to their
environment than the control group. Both groups showed significant
improvements after the sessions in the following areas indicating
the level of apathy: ‘spontaneous speech’, ‘relating to people’,
‘doing more from own initiative’, ‘active or alert’ and ‘less
bored, inactive’. The second study into Multi-Sensory Stimulation
is a randomized cross-over study, reported by Kragt et al. (1997)
and Holtkamp et al. (1997), on the within session effects on apathy
among nursing home residents in the Netherlands. The experimental
method consisted of 1:1 Snoezel sessions of half an hour to an
hour, for three successive days, by an activity therapist. The
control method consisted of staying in the living room and
receiving usual care. Participants received either the experimental
method or the control method first. Between the conditions was a
wash-out period of 4 days. Kragt et al. and Holtkamp et al. found
that participants were significantly less apathetic in the
experimental condition than in the control condition. The third
included study on the effects of Multi-Sensory Stimulation was
conducted by Robichaud et al. (1994) and measured the effects on
depression of nursing home residents and residents of a hospital
for long-term care in Canada. The experimental group followed a
Sensory Integration Group program for 30 to 45 minutes, 3 times a
week for 10 weeks provided by the first author, a doctoral student
of gerontology and geriatrics. The Sensory Integration sessions
also contained Reality Orientation and Cognitive Stimulation. The
control group took part in the usual leisure activities of their
institution. Robichaud et al. found no significant differences in
the depression change scores between the experimental and control
group. Reminiscence Two studies that were included in the review
investigated the effects of reminiscence. The aim of reminiscence
is to stimulate memory and mood in the context of the patient's
life history (APA, 1997). The first study, reported by Goldwasser
et al. (1987), measured the effects of Reminiscence Therapy Group
sessions on depression among nursing home residents in the United
States. The experimental group received Reminiscence Group Therapy
sessions of 30 minutes, twice weekly for five weeks. There were 2
control groups. The first control group attended Support Group
sessions that focused on present and future events and problems for
half an hour, twice weekly, for 5 weeks. The second control group
received usual care. The facilitators for the experimental and the
first control group were a graduate student in clinical psychology
and a social worker. The experimental group had lower self-reported
depression change scores than the control groups. It is to be noted
that the
-
52 Multi-Sensory Stimulation in 24-h dementia care
experimental group was significantly more depressed at baseline
than the control groups. The second study on reminiscence was
conducted by Namazi and Haynes (1994) and investigated the effects
of Sensory Reminiscence on apathy among nursing home residents in
the United States. The experimental group attended Sensory
Reminiscence Group sessions of 30 minutes, 3 times weekly for 4
weeks. The sensory-stimulation part consisted of colored
photographs of objects and sounds related to the objects.
Participants in the control group attended discussion sessions in
which the events of the day and future times were discussed,
without the aid of sensory stimuli for 30 minutes, 3 times a week,
for 4 weeks. Both groups were led by a trained instructor. Namazi
and Haynes found no significant differences between the
experimental group and the control group. Psychomotor therapy Two
studies into the effects of psychomotor therapy were included. The
aim of psychomotor therapy is to help people with dementia to cope
with the changes they encounter as a consequence of their disease.
Sporting activities and games are used to stimulate cognitive and
psychosocial functions (Dröes, 1991). The first study was performed
by Hopman-Rock et al. (1999) and measured the effects of
psychomotor therapy on apathy and depression among cognitive
impaired residents of homes for the elderly in the Netherlands. The
experimental group attended Psychomotor Activation Program Group
sessions provided by trained activity therapists. They were offered
the opportunity to participate in the sessions twice a week, for 6
months. Participants were included in the analysis when they had
attended at least 15 sessions during this period. The control group
participated in usual activi